SUSPECTED PEDIATRIC BONE AND JOINT INFECTIONS UNIVERSITY .

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SUSPECTED PEDIATRIC BONE AND JOINT INFECTIONSUNIVERSITY OF MICHIGAN CLINICAL PRACTICE GUIDELINEI. OVERVIEW: Bone and joint infections are relatively common invasive bacterial infections in children and adolescents.These infections can develop via hematogenous spread, via direct spread from adjacent soft tissue infection, or as a resultof trauma or surgery. In the pediatric population, these infections typically present with symptoms of fever, refusal towalk or move an extremity, or localized tenderness and inflammatory changes over a bone or joint. The most commoncausative organisms in pediatric patients include Staphylococcus aureus, Streptococcus pyogenes, and Streptococcuspneumonia. In patients 5 years, Kingella kingae is also common. Appropriate surgical management and antibiotic therapyfor these infections is important due to the relative difficulty of antibiotic penetration into bone and joint tissue. Althoughtreatable, improperly treated bone and joint infections can result in significant morbidity and even death.II. PURPOSE: The purpose of this document is to provide guidance to all medical providers in the emergency departmentor on an inpatient service who are caring for a pediatric patient with a suspected bone or joint infection. Consultants mayalso benefit from this document. Current practices are variable based on provider, and it is the hope that this guidelinewill also help to standardize the care of these patients.III. SCOPE: This guideline includes management of non-neonatal pediatric patients (from 90 days to 17 years of age)who are evaluated in the emergency department or admitted to the hospital for an acute presentation of a suspectedhematogenous (not associated with trauma or surgery) bone or joint infection. The guideline includes recommendationsfor diagnostic work-up, antibiotic therapy, and other aspects of management in the emergency department, on theinpatient floor, and at the time of patient discharge. This guideline also does not pertain to patients with chronic bone orjoint infections, or infections complicated by the presence of hardware. In those instances, it is best to discussmanagement directly with the on-call Pediatric Infectious Diseases team.IV. DEFINITIONS:- Osteomyelitis: Osteomyelitis is inflammation of the bone. In this setting, it is presumed to be due to aninfectious cause. Acute osteomyelitis is diagnosed within 2-4 weeks of symptom onset in a previously uninfectedbone.- Septic arthritis: Septic arthritis is an infection within the joint space.V. GUIDELINE:Emergency Department evaluation-Initial evaluation:o Lab work: CBC with differential, ESR, CRP, blood culture, Kingella PCR (if 5 years old). Kingella PCR: Sendout to Nationwide Children’s (order as miscellaneous sendout, test code isKNGBLD, requires 3 mL blood in an EDTA tube).o Imaging (preferably obtained before orthopedic surgery consult): X-rays: Obtain to evaluate/rule out fracture or other pathology. These may be normal in earlyosteomyelitis and cannot be used to rule out infection. Ultrasound: Obtain to evaluate for joint effusion, and/or other pathology.o Additional studies should be obtained on an individual basis, as indicated based on the history ofpresent illness.-Surgical management:o Orthopedic surgery should be consulted to evaluate for the need for further imaging (such as MRI)and/or acute surgical intervention. Osteomyelitis: Bone, fluid, and/or soft tissue specimens should be sent for Gram stain, aerobicand anaerobic culture.

oSeptic arthritis: Joint fluid should be obtained in the OR and sent for cell count and differential,Gram stain and culture, Kingella PCR (if 5 years of age). Kingella PCR: Sendout to Nationwide Children’s (test code KNGJF, requires 1 mL (0.4 mLminimum) joint fluid).In the case of suspected osteomyelitis where orthopedic surgery has decided against acute surgicalintervention, pediatric Interventional Radiology (IR) should be contacted to arrange an IR-guided bonebiopsy to be sent for Gram stain and culture. IR-guided aspirate is not necessary if the patient’s blood culture has turned positive for acausative organism in the interim.-Admission:o Pediatric orthopedic surgery will determine whether the patient will be better served on the orthopedicservice or a general pediatric service with an orthopedic surgery consult.-Empiric antibiotics:1If uncomfortable holding antibiotics, please call Pediatric Infectious Diseases to discuss prior to starting.Severe penicillin (PCN) allergy is defined by urticaria, angioedema, or anaphylaxis.2Inpatient management-Consults:o If not already done, consult Pediatric Infectious Diseases.o Orthopedic surgery will continue to follow the patient on the floor, even if there is no initial need forsurgical intervention.-Targeted antibiotics:o After culture results are available, antibiotics should be adjusted to target the appropriate organism (seeTable I). For patients with additional antibiotic allergies, resistant organisms, and/or other difficultiesselecting appropriate antibiotics, please discuss with Pediatric Infectious Diseases.Page 2 of 5

-Repeat laboratory studies:o While hospitalized, inflammatory markers should be obtained every 24-48 hours until clearimprovement noted.o If blood culture is positive, it should be repeated daily until negative for 48 hours.-Repeat imaging:o If blood cultures are persistently positive, and/or patient is still febrile, and/or exam is not significantlyimproving after 48 hours of appropriate therapy, consider repeat imaging.Discharge planning-Criteria for oral step-down therapy and discharge:o Oral therapy and discharge can be considered when following criteria are met: Afebrile Negative blood cultures 48 hours Tolerating PO Substantial clinical improvement with near return to normal function Improving inflammatory markerso See Table I for specific recommendations for oral step-down therapy.-Outpatient follow-up:o In most cases, patients will receive a minimum 3 week course of antibiotics for septic arthritis and aminimum 4 week course of antibiotics for acute osteomyelitis. Follow-up should be arranged near the end of the minimum course, which may require thepatient to be seen by a new Pediatric Infectious Diseases provider. In general, antibiotic prescriptions should be written with sufficient supply to last at leastthrough the first Pediatric Infectious Diseases follow-up appointment. Treatment courses will be extended as needed at the discretion of the Infectious Diseasesphysicians during follow-up clinic appointments.o Pediatric Infectious Diseases will arrange for repeat laboratory testing (CBCPD, ESR, and CRP), preferablyobtained just prior to Pediatric Infectious Diseases clinic visit.Page 3 of 5

Table I. Targeted antibiotics for treatment of bone and joint infectionsOrganismIV therapyOral step-down therapy1First line :Cefazolin2First line1:Cephalexin2Severe PCN orStaphylococcuscephalosporin allergy3, Severe PCN oraureus (MSSA)without bacteremia:cephalosporin allergy3:orClindamycinClindamycinculture negativeSevere PCN orSevere PCN orcephalosporin allergy3, cephalosporin allergy3:with us (MRSA)First line1, withoutbacteremia:ClindamycinWith p A or BStreptococcusClindamycin resistance:TMP-SMX2,4First line1:Ampicillin2First line1:Amoxicillin2Severe PCN orcephalosporin allergy3:ClindamycinSevere PCN orcephalosporin allergy3:ClindamycinBeta-lactamase negativeor unknown:Amoxicillin2First line1:Ampicillin2Kingella kingaeFirst line1:ClindamycinPCN allergy:CefuroximeSevere PCN orcephalosporin allergy3:TMP-SMX2,4Beta-lactamase positive:Amoxicillinclavulanate2Severe PCN orcephalosporin allergy3:TMP-SMX2,4Dosing RecommendationsAmoxicillin:33 mg/kg/dose PO q8h(max: 1000 mg/dose)Amoxicillin-clavulanate:33 mg amoxicillin/kg/dose POq8h of the 600-42.9 mg/5 mLconcentration(max: 1000 mg/dose)Ampicillin:50 mg/kg/dose IV q6h(max: 2000 mg/dose)Cefazolin:50 mg/kg/dose IV q8h(max: 2000 mg/dose)Cefuroxime:50 mg/kg/dose IV q8h(max: 1500 mg/dose)Cephalexin:37.5 mg/kg/dose PO 4 timesdaily(max: 1000 mg/dose)Clindamycin:13 mg/kg/dose IV/PO q8h(max: 900 mg/dose IV,600 mg/dose PO)TMP-SMX4:6 mg TMP/kg/dose IV/POq12h(max: 320 mg TMP/dose)Vancomycin:Pediatric vancomycin dosingguidelines1Recommendations assume organism is susceptible to listed agent. If organism is resistant, move to the nextrecommended agent or discuss with Pediatric Infectious Diseases.2Renal adjustment may be necessary. See Antimicrobial dosing recommendations for pediatric patients.3Severe penicillin (PCN) allergy is defined by urticaria, angioedema, or anaphylaxis.4TMP-SMX Trimethoprim-sulfamethoxazole.OtherDiscuss with Pediatric Infectious DiseasesPage 4 of 5

-Authors:o Elizabeth Lloyd, MD (Pediatric Infectious Diseases)o Alison Tribble, MD (Pediatric Infectious Diseases, Antimicrobial Stewardship)o Kristin Klein, PharmD (Pharmacy, Antimicrobial Stewardship)o Nicholas Dillman, PharmD (Pharmacy, Antimicrobial Stewardship)-Consultants:o Frances Farley, MD (Pediatric Orthopedic Surgery)o Michele Carney, MD (Pediatric Emergency Medicine)o Brittany Allen, MD (Pediatric Hospitalist)o Ravi Srinivasa, MD (Interventional Radiology)-Key References:o Caird M, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J BoneJoint Surg Am. 2006 Jun;88(6):1251-7.o Keren R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatmentof acute osteomyelitis in children. JAMA Pediatr. 2015 Feb;169(2):120-8.o Peltola H, et al. Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitisof childhood: prospective, randomized trial on 131 culture-positive cases. Pedatr Infect Dis J2010;29:1123-8.Antimicrobial Subcommittee Approval: N/AP&T Approval: 07/2017Revision History: C&W Operations Subcommittee 07/12/201703/21: Updated vancomyicn hyperlinkOriginated: UnknownLast Revised: 03/2021C&W Executive Committee 08/07/2017The recommendations in this guide are meant to serve as treatment guidelines for use at Michigan Medicine facilities. If you are an individual experiencing a medicalemergency, call 911 immediately. These guidelines should not replace a provider’s professional medical advice based on clinical judgment, or be used in lieu of anInfectious Diseases consultation when necessary. As a result of ongoing research, practice guidelines may from time to time change. The authors of these guidelineshave made all attempts to ensure the accuracy based on current information, however, due to ongoing research, users of these guidelines are strongly encouraged toconfirm the information contained within them through an independent source.If obtained from a source other than med.umich.edu/asp, please visit the webpage for the most up-to-date document.Page 5 of 5

SUSPECTED PEDIATRIC BONE AND JOINT INFECTIONS UNIVERSITY OF MICHIGAN CLINICAL PRACTICE GUIDELINE I. OVERVIEW: Bone and joint infections are relatively common invasive bacterial infections in children and adolescents. These infections can develop via hematogenous spread, via direct spread from adjacent soft tissue infection, or as a result

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